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The human balancing system is amazingly complex and deli- In this article we will examine the basic mechanisms involved cate, which is why it is often difficult to determine in maintaining balance, identify several of the more exactly why an individual may gradually or sud- common health issues that adversely impact the denly struggle to keep upright and move effi- body’s balancing capability, and cover some of the ciently without risking falls and injuries. interventions that can assist clients who are experi-encing balance problems. Hopefully, after com- Balance is defined as the ability to maintain the pleting this article, the reader will gain a better body’s center of mass over its base of support. A understanding and appreciation of the truly won- properly functioning balance system allows us to derful mechanisms at work which allow us to man- make postural adjustments and maintain stability under vari- age gravity’s pull on this large, spinning ball of dirt and water ous conditions and during different activities. The Coordinated Balance System
The way the human body adjusts to changes in position and maintains balance involves three phases: Sensory Input, Sensory Input
Sensory input comes from the eyes, from the muscles and sists of the Cochlea, the Vestibule, and the Semicircular Ca- joints, and from tiny structures in the ear called the Vestibu- nals, also known as the Labyrinth. Picture a snail shell with lar System. Rods and cones in the retina of the eye send im- three hula hoops attached at the front end. Inside, there are pulses to the brain that identify how a person is oriented tiny organs called the Utricle and the Saccule that detect relative to different objects. This is what enables a baseball gravity and movement in a straight line. The Utricle detects player to determine how far away a fly ball is. Information is tilting of the head, and the Saccule detects up-and-down sent to the brain so that the brain can tell him where he has movements of the head. Fluid (Endolymph) circulates with- in the semicircular canals (hula hoops) ex-erts pressure against tiny hair-like struc- There are sensory receptors in the skin, tures called Cilia. The Cilia are sensory re- ceptors that send information to the brain which perceive stretch or pressure in sur- rounding tissues and inform the brain of In Meniere’s Disease, an excess amount of fluid in this system causes increased pres- sure and vertigo (dizziness). So the Vestib- pressure is felt in the fronts of the soles of ular System acts to tell the brain about the feet, telling your brain that if you lean further, you could Sensory Input, then, is the way the body sends messages to The Vestibular System is a small apparatus located in the the brain regarding location and movement. The brain, in inner ear that provides sensory information to the brain turn, must receive the information and make decisions about about motion, equilibrium, and spatial orientation. It con- directing the body in response to those messages. Disclaimer : The information presented in this home study is intended to provide education and ideas to promote the health and well being of people with intellectual and developmental disabilities; it is in no way meant to replace a doctor’s orders or your agency’s policies. I n t e g r a t i o n
Information from the eyes, muscles and joints, and the ves- The cerebral cortex is the thinking and memory center of the tibular system is transmitted to the brain, which interprets it. brain. It contributes previously learned information. For The cerebellum is the coordination center of the brain. It example, because icy roads and sidewalks are slippery, a provides information about automatic movements that have person may elect to take a different route or cancel a trip been learned through repeated exposure to certain mo- altogether because he/she knows from past experience that tions. Gymnasts and divers have a highly developed cerebel- the ice poses a hazard to one’s balance. lum because they practice the same, complex movements The central nervous system processes the information given repeatedly, which causes the brain to adapt, allowing them to it by the body, analyzes it, and then instructs the body to M o t o r O u t p u t
“facilitation.” Practice and repetition “.synaptic reorganization goes on throughout a person’s lifetime of adjusting to changing Medical Conditions That Adversely Affect Balance
Many health problems can cause problems with a person’s ability to maintain his or her balance. We will cover some of the more common ones, how they impair balance, and what can be done to treat them. Benign Paroxysmal Positional Vertigo (BPPV)
Benign Paroxysmal Positional Vertigo usually occurs in set the balance of fluid, causing a sensation of dizziness. A people over the age of 50. Women are affected twice as physician, audiologist or therapist can treat this condition much as men. This results from a problem in the inner ear, with simple, positional exercises that help move the crys- resulting in positional vertigo. In other words, a spinning tals out of the canals and back to the Utricle. The Epley sensation results when the affected person’s head chang- Maneuver, the Sermont Maneuver, and Brandt-Daroff Ex- es position. What happens is that tiny crystals from the ercises are examples. These treatments are usually suc- Utricle called “Canaliths” or “Otoconia” migrate into one cessful in correcting the problem; they may need to be of the semicircular canals of the vestibular system and up- Meniere’s Disease
Excessive Cerumen (Ear Wax)
The cause of this condition is unknown. Some believe that Cerumen (Ear Wax) lines the auditory canal of the ear and the crystals in the vestibular system for some reason be- protects the ear from water, dust and bacteria. Sometimes come calcified, leading to increased fluid pressure in the ear wax can build up in the canal and become impacted, plac-semicircular canals. Others think that toxicity of the Cochle- ing pressure on the inner ear, leading to hearing and balance ar Nerve, perhaps from nitric oxide, is responsible. This problems. This can occur in anyone at any age, but seems to disease causes a “classic triad” of symptoms: vertigo happen much more frequently in intellectually disabled indi-(dizziness), tinnitus (ringing in the ear), and fluctuating viduals and the elderly. For some unknown reason, individu-hearing loss. Usually an ear, nose and throat physician als with intellectual and/or developmental disabilities are (otolaryngologist) diagnoses the problem. There has been much more likely to develop a problem with excessive ceru-no cure discovered yet. This disease is often treated with a men than the general population; however, no one has been medication for dizziness called Antivert (Meclizine). Some- able to establish a cause-effect relationship. If one of your times a low sodium diet is prescribed to minimize the individuals is having balance problems and trouble hearing, amount of fluid build-up in the inner ear. Unfortunately, the ask the doctor to check his/her ears. Treatment usually con-hearing loss can become permanent. Meniere’s usually sists of using ear drops to soften the wax, then flushing the affects people middle-aged and older. ears with warm water. If the ear wax has become solid, the physician may need to remove it with special instruments. Never place anything, Q-Tips included, into the ear canal; you might perforate an eardrum. Have the person see a doctor! C e r e b r a l P a l s y
Cerebral Palsy (CP) results from damage to the brain’s mo-tor control centers during pregnancy, childbirth, or in a Parkinson’s Disease
child’s first 3 years. It can be caused by an infection in the brain, head trauma, or lack of oxygen to the brain, which The cause of Parkinson’s Disease is unknown; however, it causes abnormal bodily movements. The most common occurs when there is not enough dopamine produced in the type is Spastic CP, in which a person has tight, spastic mus- brain. Dopamine is a chemical that is responsible for sending cles which limit the ranges of motion of one or more joints. signals to the part of the brain that controls smooth move- Those individuals who can ambulate may walk on their toes ment. Without it, the affected person will start having trem- or in a scissor-like manner (knees cross each other). Bal- ors, stiffness, slow movement, and balance problems. The ance is often poor and there is an increased risk for falls. disease usually begins after age 50, and is progressive (it The disease is not progressive; in other words, it does not worsens over time), resulting in a stooped-forward posture, worsen over one’s lifetime. Treatment includes physical slow, shuffling gait, poor balance and a high risk for falls. therapy, massage therapy, botox injections, and biofeed- Medications such as Carbidopa/Levodopa and Requip help slow the progress of the disease, but there is no cure as of yet. Muscular Dystrophy
Muscular Dystrophy (MD) is a group of diseases character- Multiple Sclerosis
ized by progressive muscle weakening and disability. It is Multiple Sclerosis (MS) is an inflammatory, auto-immune considered genetic in nature. Some individuals with MD disease in which the body’s own immune system attacks experience rapid progression and early death while others the nervous system, causing breakdown and scarring of have milder cases with slow progression, live many years, myelin, the substance that covers and protects the nerves. and function quite well. MD can cause serious problems Symptoms can vary from mild to severe, but often there is with ambulation and balance and can lead to total immobili- muscular weakness and poor coordination. In some people, ty. No cure has been discovered. People who have a family the disease is progressive, and in others there are remis- history of MD should see a genetic counselor before having sions and relapses. Treatment is with drug therapy and su- children; the odds of passing the disease on to children are pervised exercise. There is no cure as of yet. Other Conditions That Can Affect Balance
There are several other neurological problems that can interfere with a person’s balance (Lou Gehrig’s Disease, Guillain-Barre Syndrome, Huntington’s Chorea, diabetic neuropathy, brain tumors/cancer, dementia, head trauma, disc herniations). Also, non-neurological conditions that limit range of motion or cause pain can impair balance. Heart disease, stroke, emphysema, Chronic Obstructive Pulmonary Disease (COPD), and eye problems such as macular degeneration, cataracts, glaucoma and blindness all increase the chances for falls. Rheumatoid arthritis, osteoarthritis, degenerative joint disease, or myofascial pain syndrome (a condition in which trigger points in muscles cause referred pain and dysfunction) may alter a person’s gait and place him at risk for falls and injuries. These problems are managed in a variety of ways, including physical therapy, anti-inflammatory medications, pain medications, myofascial release, trigger point therapy, injections, and, in some cases, surgery (which may include joint replacement). Another non-neurological problem that is quite common, especially among the elder-ly, is that of Orthostatic (or Postural) Hypotension. Orthostatic Hypotension
Orthostatic Hypotension is a condition in which a person’s blood pressure drops significantly when he or she moves from lying down to standing up. The drop in pressure creates a feeling of light-headedness or dizziness, and therefore significantly in-creases the risk of falls and injuries. If you are caring for a person who experiences these symptoms, have him or her see the doctor. He can determine if the reason is a cardiovascular problem, a neurological problem, low blood volume, or the side effect of a medication. Treatment depends on the cause. Sometimes having the patient do some simple exercises before get-ting up from the bed or chair (toe raises, thigh contractions, leg raises for 30-60 seconds) can help improve circulation and prevent a drop in blood pressure. Ultimately the cause must be discovered and treated for lasting relief. Sometimes the cause may be due to medications. This problem is most often seen in elderly persons, because in many cases they are dealing with several chronic health problems and take multiple medications. Medications
There are literally thousands of medications used to treat health problems in our country today. Many of them can interfere with a person’s ability to maintain balance, and thus contribute to falls and injuries. Some medications can cause drowsiness, confusion or disorientation. Some can affect circulation and cause blood pressure changes. Others may impact judgment and decision-making. The senses (particularly vision and touch) can be adversely affected by medications. All of these things can change a person’s ability to counter gravity effectively. To follow is a list of several of the main types of medications (with a few examples of each) that often produce side effects that impair balance. It is by no means exhaustive, but will give an idea of how many medications can contribute to this problem: Antipsychotics: Thorazine, Compazine, Trilafon, Haldol, Navane, Zyprexa, Risperdal, Seroquel Antidepressants: Wellbutrin, Elavil, Celexa, Cymbalta, Lexapro, Paxil, Zoloft, Effexor, Prozac, Trazodone Anticholinergics: Cogentin, Atrovent, Spiriva, Detrol, Benadryl, Dramamine Benzodiazepines: Xanax, Ativan, Valium, Klonopin Hypnotics: Phenobarbitol, Ambien, Alcohol Dopaminergics (Anti-Parkinsonian): Levodopa, Sinemet, Requip, Mirapex, Parlodel Antihypertensives (Blood Pressure Meds): Avapro, Cozaar, Diovan, Capoten, Prinivil, Vasotec, Zestril, Coreg, Inderal, Lopres-sor, Norvasc, Procardia, Cardura, Catapres, Aldactone, Bumex, Dyazide, Lasix Cardiac Medications: Lanoxin, Digoxin, Isordil, Atenolol Narcotic Analgesics (Pain Relievers): Fentanyl, Dilaudid, Demerol, Methadone, Morphine, Codeine, Hydrocodone, Oxycodone Anticonvulsants (Anti-Seizure): Phenobarbitol, Carbamazepine, Depakote, Gabapentin, Dilantin, Primidone, Lamotrigine Antihistamines: Allegra, Benadryl, Claritin, Zyrtec, Tylenol Cold and Flu Oral Hypoglycemics: Glipizide, Glyburide, Metformin, Avandia, Actos How to Help
Observation
Consult the Support Plan
People who experience problems with balance can benefit if Reviewing a client’s support plan can give information about their caregivers pay close attention when they observe them his medical conditions, medications, and plan of care. Under- go about their daily activities. Sometimes subtle changes in standing a client’s background is crucial in preventing inju- the way a person walks or transfers can be clues to a problem ries. For example, if he has a diagnosis of Meniere’s Disease, which may lead to a fall or injury. Even worse, these things you know he is at risk for a fall and that he probably has med- can indicate a serious underlying medical condition. The ication available for his dizziness, and there may be instruc- problem is often compounded when dealing with individuals tions regarding supervision or hands-on assistance for certain who are intellectually or developmentally disabled, because often, they may not be able to tell you what they are experi-encing. So your assessment skills are very important in keep-ing your clients safe. It is important also to observe a client closely when he or she begins taking a new medication. Create a Safe Environment
Refer to an Appropriate Healthcare Professional
Even for people who do not experience any particular bal- When you suddenly notice something “different” about a ance problems, this is a no-brainer. Maintaining a well-lighted client’s ability to transfer, dress himself, or bathe, or you see dwelling place that is free of clutter and hazards (such as wet that he is limping or staggering, he may be tired or in pain. It floors) will reduce that likelihood of falls an injuries. Always may be a manifestation of a chronic disease he has been deal- be aware of potential obstacles and dangers in the home or ing with, the result of an injury, or a side effect of a medica- tion. Or he may be experiencing a serious problem such as a stroke. It is always best in such situations to send him to the Emergency Room. The mechanisms of the human body that enable us to maintain our bal-ance every moment of every day are truly amazing in their complexity and in their efficiency. Yet, as we have seen, problems can arise with this system due to diseases, infections, injuries or medications. This review is by no means comprehensive, but hopefully it will help you understand a bit more about how the body works to counter gravity, some of the more common problems that confront us in this struggle, and a few simple ways in which we can assist people who face challenges in this area. Balance Test
Name: _________________________________________ Title: _______________________________________ Agency: ________________________________________ Date: ______________________________________ Please provide contact information (email or mailing address, fax number ) where you would like your certificate to be sent: ______________________________________________________________________________________________ ______________________________________________________________________________________________ 1. Which of the following types of medications can create problems with a person’s balance? a. Antipsychotics b. Anticonvulsants (Anti-Seizure) c. Narcotic Pain Relievers d. All of the Above 2. Being helpful to clients who have balance problems involves: d. Referring them to the appropriate healthcare professional 3. If you notice a sudden difference in a client’s balance or ability to perform his daily activities, it is best to: a. Have him do toe raises, thigh contractions, and leg raises before getting out of bed b. Give him a walker to keep him from falling d. Send him to the emergency room; he might have a serious medical problem 4. A Support Plan can be helpful in caring for clients with balance problems because: a. It fits around his waist and will support him b. It contains information about his medical conditions, medications and plan of care c. It presents a list of reasons for why he has an unsteady gait d. It has a list of all of his informal support persons 5. Someone with Parkinson’s Disease will most likely present with You must get a score of at least 80% to pass this course; please submit your completed test to receive 1 hour of
training credit for this course.
To submit via fax, please fax this page to 814-728-8887. To submit via email, please send an email to training@northwesthc.org. Please put “Balance Test” in the sub-ject line, and the numbers 1—5, along with your answers, in the body of the email. To submit via mail, send this page (or a copy) to NWHC, 1020 Pennsylvania Avenue West, Warren, PA 16365. Northwest Health Connections
Evaluation of Training
Please check the box that best describes your role: c Direct Support Professional c Provider Administrator/Supervisor c Program Specialist c Provider Clinical Staff c Consumer/Self-Advocate c Family Member c Support Coordinator c Support Coordinator Supervisor c PCH Staff/Administrator c FLP/LSP c County MH/MR/IDD c Other (please list): __________________________________________ Please circle your PRIMARY reason for completing this home-study training: Please circle the best response to each question. As a result of this training, I have increased my knowledge. I learned something I can use in my own situation. This training provided needed information. The training material was helpful and effective. Overall, I am satisfied with this training. Additional information I feel should have been included in this training: I would like to see these topics/conditions developed into home-study trainings:

Source: http://www.northwesthc.org/trainings/homestudy/balance.pdf